Evidence of Coverage Errata Sheet - Mercy Care Plan

Errata Sheet to theMercy Care Advantage (HMO SNP)2013Evidence of CoverageJune 2013Dear Member,This is important information on changes in your Mercy Care Advantage coverage.We previously sent you the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)documents which provide information about your coverage as a member of our plan. This noticeis to let you know there are errors in your EOC document. Below you will find informationdescribing and correcting the errors. Please keep this information for your reference.Changes to your EOCWhere you can find the errorin your 2013 EOCOn page 1, of Chapter 1 “Gettingstarted as a member”, under“Section 3, What other materialswill you get from us” there aretwo sub-topics numberedincorrectly.Original InformationSection 3.4 The plan’s Listof Covered Drugs(Formulary)Section 3.5 TheExplanation of Benefits(the “EOB”): Reports witha summary of paymentsmade for your Part Dprescription drugsCorrected InformationSection 3.3 The plan’s List ofCovered Drugs (Formulary)Section 3.4 The Explanationof Benefits (the “EOB”):Reports with a summary ofpayments made for your PartD prescription drugsOn page 7, of Chapter 1, there isan error in the header text of“Section 3.4. A symbol isinserted instead of the requiredtext.Section 3.4 The π (the“EOB”): Reports with asummary of paymentsmade for your Part Dprescription drugsSection 3.4 The Explanationof Benefits (the “EOB”):Reports with a summary ofpayments made for your PartD prescription drugs

On page 15, of Chapter 2, underthe section titled “How to contactus when you are making anappeal about your Part Dprescription drugs,” the title ofthe first table is incorrect.Incorrect Title: CoverageDecisions for Medical CareCorrect Title: Appeals forPart D Prescription DrugsOn page 36, of Chapter 4, the“Section 1.3 header is printedtwice on the page.On page 38, of Chapter 4, in theBenefits chart, under “Servicesthat are Covered for You,” the“Annual Wellness Visit” benefitinformation is missing.Duplicated text: “Section1.3 What is the most youwill pay for Medicare PartA and Part B coveredmedical services?”Missing “Annual WellnessVisit” benefit information.This section should haveonly printed once on page36.Annual Wellness VisitServices that are covered foryou:If you’ve had Part B forlonger than 12 months, youcan get an annual wellnessvisit to develop or update apersonalized prevention planbased on your current healthand risk factors. This iscovered once every 12months.Note: Your first annualwellness visit can’t takeplace within 12 months ofyour “Welcome toMedicare” preventive visit.However, you don’t need tohave had a “Welcome toMedicare” visit to becovered for annual wellnessvisits after you’ve had Part Bfor 12 months.What you must pay whenyou get these services:There is no coinsurance,copayment, or deductible forthe annual wellness visit.

On page 39, of Chapter 4, in theBenefits chart, under “Servicesthat are Covered for You,” the“Bone mass measurement”benefit information is missing.Missing “Bone massmeasurement” benefitinformation.Bone mass measurementServices that are covered foryou:For qualified individuals(generally, this means peopleat risk of losing bone mass orat risk of osteoporosis), thefollowing services arecovered every 24 months ormore frequently if medicallynecessary: procedures toidentify bone mass, detectbone loss, or determine bonequality, including aphysician’s interpretation ofthe results.What you must pay whenyou get these services$0 copay for all preventiveservices covered underOriginal Medicare at zerocost sharing.Any additional preventiveservices approved byMedicare mid-year will becovered by the plan or byOriginal Medicare.On page 40, of Chapter 4, in theBenefits chart, under“Chiropractic services,” the word“chiropractic” is missing from the“What you must pay when youget these services” column andthe prior authorization statementis missing.0% or 20% of the cost foreach Medicare coveredvisit.*Missing PriorAuthorization may apply0% or 20% of the cost foreach Medicare coveredchiropractic visit.*Prior Authorization mayapply.

On page 56, of Chapter 4, in theBenefits chart, under “Outpatientsubstance abuse services,” thebenefit description for“Outpatient substance abuseservices” is missing.The benefit description for“Outpatient substanceabuse services” is missing.Outpatient substance abuseservicesCovered services include:Substance abuse mental healthservices provided by astate-licensed psychiatrist ordoctor, clinical psychologist,clinical social worker, clinicalnurse specialist, nursepractitioner, physicianassistant, or otherMedicare-qualified mentalhealth care professional asallowed under applicable statelaws.On page 57, of Chapter 4, in theBenefits chart, under “Podiatryservices,” the benefit descriptionand cost sharing amount for thesupplemental routine podiatryvisit(s) is incorrect.0% or 20% of the cost foreach Medicare-coveredpodiatry visit.*0% of the cost for coveredsupplemental routine visits.Up to 1 supplemental routinepodiatry visit(s) every threemonths.0% or 20% of the cost foreach Medicare-coveredpodiatry visit*On pages 60 and 61, of Chapter4, in the Benefits chart, the“Services to treat kidney diseaseand conditions,” benefitdescription is printed twice.Duplicated text: “Servicesto treat kidney disease andconditions.”The benefit description for“Services to treat kidneydisease and conditions”should have only printedonce on page 60.On page 72, of Chapter 5, under“Section 3.3 Using the plan’smail-order services,” in the 7 thparagraph, the CVS CaremarkCustomer Care (voice) phonenumber is incorrect.“If you have not receivedan order within 14 calendardays of when you sent theorder, call CVS CaremarkCustomer Care at 1-800-522-8159 (voice) or (TTY1-800-231-4403) and theywill begin processing areplacement order.”“If you have not received anorder within 14 calendardays of when you sent theorder, call CVS CaremarkCustomer Care at 1-800-552-8159 (voice) or (TTY 1-800-231-4403) and they willbegin processing areplacement order”.

On page 92, of Chapter 6, under“Section 5.3 A table that showsyour costs for a long-term (up toa 90-day) supply of a drug,” oneof the Generic Drug Cost-Sharingamounts for mail order service inthe table is incorrect.In the table:Generic Cost-Sharing forThe plan’s mail-orderservice (90 day supply):$0 or$1.15 or$2.60In the table:Generic Cost-Sharing forThe plan’s mail-orderservice (90 day supply):$0 or$1.15 or$2.65On page 93, of Chapter 6, under“Section 5.5 How Medicarecalculates your out-of-pocketcosts for prescription drugs,” theheader in the section describingyour out- of- pocket costs isincorrect.Incorrect Header: Thesepayments are not includedin your out-of-pocket costsCorrect Header: Thesepayments are included inyour out-of-pocket costsOn page 147, of Chapter 9, under“Section 8.2 Step-by-step: Howto make a Level 1 Appeal tochange your hospital dischargedate,” the header for “Step 2: TheQuality ImprovementOrganization conducts anindependent review of yourcase.” is missing.The header for “Step 2”The Quality ImprovementOrganization conducts anindependent review of yourcase.” is missing.The missing header shouldhave been printed directlyunder the box stating: “Legalterms – A “fast review” isalso called an “immediatereview” or an “expeditedreview” and before the textstating: “What happensduring this review?”On page 166, Chapter 9, under“Section 12 Handling problemsabout your Medicaid benefits,”there is some incorrect on thepage.Incorrect text: “ANTINFORMA TION 34” islisted directly above theDepartment of EconomicSecurity address.This text is a typo and doesnot apply to this section.

You are not required to take any action in response to this document, but we recommend youkeep this information for future reference. If you have any questions please call us at602-263-3000 and toll-free 1-800-624-3874 (TTY/TDD 1-866-602-1982), 24 hours a day, 7 daysa week.We apologize for these errors and any inconvenience we have caused you.Mercy Care Advantage is a Coordinated Care Plan with a Medicare contract and a contract withthe Arizona Medicaid program.This information is available for free in other languages. Please contact our customer servicenumber at 1-800-624-3879, 24 hours a day, 7 days a week. TTY users should call1-866-602-1982, 24 hours a day, 7 days a week for additional information.Este documento está disponible en formatos o idiomas diferentes. Para obtener más información,llame al, 1-800-624-3879, las 24 horas del día, los 7 días de la semana. Los usuarios de TTYdeben llamar al, 1-866-602-1982, las 24 horas del día, los 7 días de la semana.H5580_13_035 CMS Approved 06/24/2013